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".Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i FOR OFFICE USE: APPLICATION <br /> «r►_ (For Non-Transferable, Revocable', Suspendable) <br /> 4 4..4 PUMP&WELL <br /> - ENVIRONMENTAL HEALTH PERMIT <br /> 4 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> r Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install the work.hereindescribed..Thisapplication is <br /> f made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Lpcgl Health District. <br /> Exact Site Address Sow➢ r City/Town p� <br /> i Owner's Name Chi-d la 4)II Y1 ' Phone <br /> Address a- Sdee -_ IS-M r-n c City— <br /> Contractor's <br /> ity Contractor's Name �' �� License# Business Phone d y Zd 7 4 <br /> Contractor's Address .V ZF Emergency Phone i <br /> Is Certificate of Workman's Compensation Insurance o r/14ile With SJLHD? Yes X No y <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ `� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 19 40 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> h Sewage Disposal Field — �--=Cesspool/Seepage Pit Other <br /> f Property Line Private Domestic_Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑'DRILLED r Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC '. ❑" DRIVEN Gauge of Casing _ T <br /> 19 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal " <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER _ Other Information <br /> ❑ GEOPHYSICAL Surface Seal Instal ed By: <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: © State Work Done- <br /> PUMP <br /> onePUMP REPAIR: State Work Done RaO21A <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the Work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspe Con p r o gr ting,and a final inspection. <br /> Signed F file: ��� Date: <br /> (Draw Plotlan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date 1 1 <br /> Additional Comments: <br /> �n <br /> Phase 11 Grout Inspection 4r Phas III Final Inspection <br /> Inspection By Date Inspection By�7 �trcGrs✓ Date <br /> Fee Is.Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - <br /> REMIT <br /> BILLING REMITTANCE $ <br /> i BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER - - <br /> i � - <br /> � <br /> Received by Date - Receipt No. Permit Nc- Iss ante❑ e y-"Mailed Delivered <br /> a <br /> j`.. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONM ENTAL'HEALTH PERMIT/SERVICES' '�•-�. -1601 E'.HAZELTON AVE-,P.O.Bo:2009 STOCi(TON,CA 95201 <br />